Citation Nr: 22017569 Decision Date: 03/25/22 Archive Date: 03/25/22 DOCKET NO. 15-00 810 DATE: March 25, 2022 ORDER Entitlement to service connection for a hiatal hernia, to include as secondary to service-connected disabilities is granted. FINDINGS OF FACT 1. The Veteran's service-connected posttraumatic stress disorder (PTSD) and subsequent treatment caused him to become obese. 2. The Veteran's obesity was a substantial factor in causing his current hiatal hernia. CONCLUSION OF LAW The criteria for entitlement to service connection for hiatal hernia, to include as secondary to service-connected disabilities have been met. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran had active service from September 1968 to June 1970, including service in the Republic of Vietnam. This matter was previously before the Board in January 2019 but was remanded to the Agency of Original Jurisdiction (AOJ) for further development. Specifically, the AOJ was required to obtain a medical opinion regarding the etiology of the Veteran's hiatal hernia. The required medical opinion was obtained and associated with the claims file in January 2022. Accordingly, the Board finds there has been substantial compliance with the remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). The third step of this inquiry requires the Board to weigh the probative value of the evidence in light of the entirety of the record. 1. Entitlement to service connection for hiatal hernia, to include as secondary to service-connected disabilities Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. In order to prevail on the issue of service connection there must be competent evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a nonservice-connected disability which is aggravated by a service-connected disability. In such an instance, the Veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b); see Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Veteran claims entitlement to service connection for hiatal hernia. His diagnosis of hiatal hernia was confirmed in a January 2022 Esophageal Conditions examination. At the examination, the Veteran stated he was first diagnosed with a hiatal hernia in 2013. He does not claim, and the record does not establish, that his hiatal hernia was incurred during his active service. In an August 2020 informal hearing brief, the Veteran's representative argued that the Veteran's obesity was an intermediate step leading to his hiatal hernia. Although service connection is not allowed for obesity on its own, obesity can act as an "intermediate step" to establish service connection for another disability as secondary to an already service-connected disability under certain circumstances. See VAOPGCPREC 1-2017. The VA General Counsel has indicated that establishing service connection in a case such as the Veteran's requires resolution of three issues: (1) whether the service-connected disability caused the Veteran to become obese; (2) if so, whether the obesity due to the service-connected disability was a substantial factor in causing the claimed disability; and (3) whether the claimed disability would not have occurred but for obesity caused by the service-connected disability. Id. In a more recent decision, the Court modified the analysis set out in the General Counsel's opinion, holding that in considering whether obesity is an "intermediate step," consideration must be given to whether obesity was caused or aggravated by a service-connected disability, consistent with 38 C.F.R. § 3.310. Walsh v. Wilkie, 32 Vet. App. 300 (2020). In Garner v. Tran, 33 Vet. App. 241 (2021), the Court held that to reasonably raise a theory of secondary service connection via obesity as an intermediate step, there must be some evidence in the record which draws an association or suggests a relationship between the veteran's obesity, or weight gain resulting in obesity, and a service-connected condition. The Court set forth a non-exhaustive list of considerations that could reasonably give rise to such a theory, including lay statements by a veteran attributing weight gain or obesity to the service-connected disability. The Court explained the critical commonality among its nonprecedential decisions was that "there is some evidence in the record which draws an association or suggests a relationship between the veteran's obesity, or weight gain resulting in obesity, and a service-connected condition." In January 2022, the VA obtained a medical opinion regarding etiology of the Veteran's hiatal hernia. The VA medical opinion is adequate because it was based upon consideration of the Veteran's pertinent medical history, his lay assertions and current complaints, and because it describes his hiatal hernia in detail sufficient to allow the Board to make a fully informed determination. Ardison v. Brown, 6 Vet. App. 405, 407 (1994). The medical opinion concludes that the Veteran's PTSD likely contributed to his weight gain, noting: PTSD is independently associated with a higher risk of weight gain and loss, the former of which leads to a higher prevalence of overweight and obesity and a higher risk of comorbidities associated with excessive body adiposity. Therefore, the PTSD likely contributed to weight gain. The examiner also found it was at least as likely as not that the Veteran's hiatal hernia would not have occurred but for his obesity. The examiner reasoned, "it is medically known that obesity is the strongest risk factor for developing a hiatal hernia." (Continued on the next page) Based on the January 2022 medical opinion, the Board finds that the Veteran's PTSD caused him to become obese, and that obesity was a substantial factor in causing the Veteran's hiatal hernia. Accordingly, entitlement to service connection for a hiatal hernia is warranted. D. Martz Ames Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Riordan, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.